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Wiki Risk of Complications and/or Morbidity or Mortality of Patient Management Cam Walker Boot
- Thread starter angeema
- Start date
amyjph
True Blue
You could think about it in terms of the "old" office/outpatient MDM table. Simple sprain, PT/OT, OTC drugs and "minor surgery" w/ no risk is considered low in that case.
If it's just a simple sprain with no co-morbidities and they are not prescribed anything other than OTC pain meds and rest I would call it low. I would assume they probably ordered/reviewed X-Rays and it's an acute, uncomplicated inury? Hard to say without the notes. It's probably level 3.
If it's just a simple sprain with no co-morbidities and they are not prescribed anything other than OTC pain meds and rest I would call it low. I would assume they probably ordered/reviewed X-Rays and it's an acute, uncomplicated inury? Hard to say without the notes. It's probably level 3.
Yes, I also want to refer to the old guidelines with the presenting problem "sprain"-Low. There was actually no xray performed-No Data, and no prescription or OTC drugs, only the Cam Boot was applied. So that leaves us to where does the Cam Boot fall on the management options. Is it considered "elastic bandages"?
amyjph
True Blue
Any chance the time is documented so you could use that? 
If not, I would call it a 3 and move on with my life. A CAM boot is more than just Ace wraps. If you wanted to be conservative you could call it a 2 but I doubt any auditor would cite a 3.
This helps me sometimes when I can't decide: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/EMScoreSheet
Just an example I found googling: https://www.ohsu.edu/sites/default/...t Coding - Oregon Rural Health - handouts.pdf
Example – 23yo patient comes in with complaint of sprained ankle 5 days ago. Was unable to go to work due to pain with standing. Better now and states that he just needs note to return to work. Ankle still slightly swollen and bruised. Xray confirms no fracture – normal ankle. Advised to rest, ice, elevate and return to work in 2 days. Note given. Expanded Problem-Focused History and Examination • Current Guidelines – 99202/99213 • 2021 Guidelines – 99203/99213 Medical Decision-Making • Low: Acute uncomplicated illness or injury – 99203/99213 • Straightforward: 1 test ordered, reviewed – 99202/99212 • Low: (No examples given.) 99203/99213
If not, I would call it a 3 and move on with my life. A CAM boot is more than just Ace wraps. If you wanted to be conservative you could call it a 2 but I doubt any auditor would cite a 3.
This helps me sometimes when I can't decide: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/EMScoreSheet
Just an example I found googling: https://www.ohsu.edu/sites/default/...t Coding - Oregon Rural Health - handouts.pdf
Example – 23yo patient comes in with complaint of sprained ankle 5 days ago. Was unable to go to work due to pain with standing. Better now and states that he just needs note to return to work. Ankle still slightly swollen and bruised. Xray confirms no fracture – normal ankle. Advised to rest, ice, elevate and return to work in 2 days. Note given. Expanded Problem-Focused History and Examination • Current Guidelines – 99202/99213 • 2021 Guidelines – 99203/99213 Medical Decision-Making • Low: Acute uncomplicated illness or injury – 99203/99213 • Straightforward: 1 test ordered, reviewed – 99202/99212 • Low: (No examples given.) 99203/99213